WARNING - Waiver Has Not Been Signed - Please confirm this action
Have you ever had a professional massage? Y N
Are you taking any medications? Y N
Please list them and what they are for:
List previous injuries or surgeries:
(Please indicate areas of tension or discomfort on the pictures above.)
Present symptoms/ Current complaints:
I understand that a massage therapist does not diagnose illness or disease, prescribe medicine, nor perform spinal manipulation.
I further understand that massage therapy is for the purpose of reducing stress, muscular spasm or pain, and for improving circulation, energy and sense of well-being.
I agree that a 24-hour notice for a change or cancellation of an appointment is necessary. I understand I am responsible for payment for the full amount of the scheduled service or services.
(draw your signature)
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